Economic burden of revision hip and knee arthroplasty in Medicare enrollees.

UNLABELLED: The economic burden to Medicare due to revision arthroplasty procedures has not yet been studied systematically. The economic burden of revisions was calculated as annual reimbursements for revision arthroplasties relative to the sum total reimbursements of primary and revision arthroplasties. We evaluated this revision burden for total hip and knee arthroplasties through investigation of trends in charges and reimbursements in the Medicare population (Parts A and B claims from 1997-2003), while taking into account age and gender effects. Mean annual economic revision burdens were 18.8% (range, 17.4-20.2%) and 8.2% (range, 7.5-9.2%) for total hip arthroplasties and total knee arthroplasties, respectively. Procedural charges increased while reimbursements decreased over the study period, with higher charges observed for revisions than primary arthroplasties. Reimbursements per procedure were 62% to 68% less than associated charges for primary and revision total hip and knee arthroplasties. The effect of age and gender on reimbursements varied by procedure type. Unless some limiting mechanism is implemented to reduce the incidence of revision surgeries, the diverging trends in reimbursements and charges for total hip and knee arthroplasties indicate that the economic impact to the Medicare population and healthcare system will continue to increase. LEVEL OF EVIDENCE: Prognostic study, level II-1 (retrospective study). See Guidelines for Authors for a complete description of levels of evidence.

A mathematical algorithm to identify toxicity and prioritize pollutants in field sediments.

In order to evaluate sediment toxicity, a mathematical algorithm was developed to compute the toxicity of multiple component mixtures acting in an additive manner. A statistical approach was devised to determine the presence of potential interactive effects among mixture components. The algorithm uses three kinds of data to obtain an integrative approach to sediment toxicity assessment: Microtox toxicity data (EC50 values), sediment pollutant concentration measurements, and sequential extraction (SEQ) data to investigate metal partitioning. To simplify the analysis of complex mixtures using a prioritization scheme based on intrinsic toxicity and relative abundance, a toxicity index (TI) was employed as an indicator of adverse ecological impact. In general, the ranking of contaminants using the TI approach was found to be most efficient in reducing computational time, and concentrations using bioavailability data from SEQ was found to be the best theoretical predictor of the experimental mixture toxicity value. Only a few pollutants that were present at the greatest abundance were needed to provide a good approximation of the calculated EC50 found when all components were included. Not only does this substantially reduce the computational time needed to determine the EC50, it could in some cases dramatically reduce the pollutant monitoring effort required to track toxicity effectively. This approach would have substantial implications for both risk assessment and for remediation strategies, making them more efficient by focusing on the priority pollutants identified.

Correlation of field-measured toxicity with chemical concentration and pollutant availability.

Direct field toxicity tests were performed in two Louisiana waterways, Bayous Trepagnier and St. John, on sediments containing organic/heavy metal mixtures. Our approach involved bioluminescent bacterial toxicity assays (using DeltaTox, which qualitatively identifies polluted areas, and Microtox, which quantifies toxicity). Samples were more completely analyzed in our laboratory using inductively coupled plasma atomic emission spectroscopy (ICP-AES) and gas chromatography/mass spectrometry (GC/MS). Results indicate that lead is the primary toxic metal at the sites examined, though concentrations of metals fluctuate due to spatial variation and the dynamic nature of the waterways. Polycyclic aromatic hydrocarbons (PAHs) are the most abundant group of organics measured and appear to contribute to the overall toxic response. DeltaTox located toxic hotspots where there was an average light loss of 53-100%. Toxicity results from both assays agree but are well correlated with concentration measurements only for certain sediment fractions. Overall, the DeltaTox/Microtox approach appears to be rapid and cost effective for on-site hotspot identification, and may increase understanding of hazards associated with heavy metal and organic contaminants in these waterways.